Why women's hormone problems get missed: blind spots in medicine and research

The Short Version

Four doctors from different corners of medicine describe the same gap from different sides. Amy Shah traces it to research: women were excluded from medical studies, and even now studies rarely measure what drugs do to estrogen, progesterone or testosterone [1]. Rachel Rubin, a urologist, traces it to training: gynecology doesn't cover sexual medicine and other doctors assume women's problems belong to gynecology, so cheap, long-known treatments go unprescribed [2]. Mary Claire Haver, an OB-GYN, admits she was once part of the problem, sending women away with referrals instead of considering hormones, and points to a research and funding gap for a stage that covers a third of women's lives [3][4], while Sharon Malone says the deepest problem is that nobody tells women their hormonal life is "one continuous story" [5]. Put together, they explain why symptoms get treated one at a time by different specialists, written off as stress or aging, or never connected to hormones at all [1][2][3][5].

Table of contents

What They Said

Amy Shah: a knowledge gap built into medicine

Amy Shah is a medical doctor trained in nutrition at Cornell, with residency at Harvard and a fellowship at Columbia, and the author of I'm So Effing Tired [1]. Speaking with Mel Robbins, she says menopause is discussed constantly among friends but rarely in medicine [1].

Women left out of the research. "I was in school when they actually mandated that women be included in medical studies," Shah says [1]. Before that, "Women were excluded from all medical studies because our fluctuating hormones or the fact that we could be pregnant during a time of a trial. And so every medication, every intervention, every surgery, everything was done only on men." [1] Her recollection is that inclusion was mandated around the 1980s [1]. In the meantime, "what they were just doing is they would just prescribe a smaller dose to women," treating women as smaller men, "And that's why women are the forgotten gender when it comes to healthcare." [1]

Included, but still not measured. Inclusion did not close the gap. Shah says "what they weren't doing and they still don't do is they weren't seeing the impact on hormones" [1]. Even now, studies rarely measure effects on estrogen, progesterone or testosterone [1]. She also laments that there are no large studies of women's cycles: "we don't have 10,000 women studies where we look at their cycles and we look at menopause. I mean, we need that. We need that data." [1] "The problem is the world is a man's world, at least the medical research world because that's what we've researched." [1]

Her own experience. When Shah was a young mother, she felt burned out yet couldn't sleep, and her hair was falling out, though her thyroid levels were fine [1]. She went to colleagues who specialized in women's health, "And they said to me, oh, we didn't learn about that either." [1] What they had learned, she says, was "pregnancy, puberty" [1]. What they learned about menopause, she says, was that "it just shuts off and that's basically all we know" [1].

The blind spots keep going. Asked whether women of different races experience menopause differently, Shah says "we don't even know the differences between different backgrounds, different races, different ethnicities. Because they're not studying it." [1] "We're just at the basic levels of finding out that women present differently with heart attacks than men." [1]

Medical gaslighting. Shah's biggest pet peeve is the shame women feel and the way many are dismissed by providers [1]. She says many are sent home with anti-anxiety medication without any explanation of hormonal changes [1]. "I think that term is like gaslighting, like medical gaslighting women just feel like they're not listened to and their complaints are just dismissed." [1] Women in their 40s, 50s and 60s, she says, deserve better: "These people are running companies, they're leading countries." [1]

Connect the symptoms. Her message to the medical community is about pattern: "if a woman comes with you to you with these complaints, don't just write it off as separate things. Think about where she and her cycles, where she with her hormones" [1]. She also pushes back on a common myth: menopause "is a diagnosis of symptomology, and the definition has nothing to do with the level of hormones," so expensive testing is mainly for troubleshooting therapy, not diagnosis [1]. She notes the supplement market for PMS and menopause is a wild west, a sign women are searching for answers [1]. Her advice is to seek out physicians who are "interested, educated, and can be an advocate for you" [1].

Rachel Rubin: a gap in medical training

Rachel Rubin is a board-certified urologist and sexual medicine specialist [2]. Her argument is that many urinary and sexual problems women are told to live with have a hormonal basis, and that inexpensive, long-established treatments exist but are rarely offered because doctors were never trained in them [2].

Nobody owns it. Rubin says the common assumption that gynecologists handle everything for women is mistaken, because gynecology training covers reproductive health and gynecologic cancers but not sexual medicine [2]. She states that the word clitoris does not appear in what a gynecologist must know to finish training [2]. Urology has long treated men's sexual function and testosterone, while women's sexual health has been ignored [2]. Meanwhile other specialties step back: "because we decided that all women's health goes to gynecology, right? No other doctor needs to know about women's stuff because you just go to your gynecologist." [2] The result, in her telling, is not bad doctors but untaught ones, and she wishes more would simply say they did not learn this [2].

What women hear instead. Patients report being told to drink a glass of wine, read an erotic novel, have more sex to fix painful sex, or accept that this part of life is over [2]. Rubin urges women to notice whenever they tell themselves something is just aging or just stress, such as waking more at night to urinate, drier or more painful sex, slower or missing orgasms, or not feeling like oneself [2]. In her words, "Low libido is a medical condition if you are bothered by it" [2].

Known for decades, rarely prescribed. Her clearest example is urinary tract infections. One thing doctors get wrong, she says, is "that we treat all UTIs just with antibiotics," but "You treat the infection, but you have to get to the underlying root cause problem, which is the hormonal shifts that are happening with the woman in front of you." [2] Vaginal hormones, whether vaginal estrogen or vaginal DHEA, "prevent urinary tract infections by more than half. But Mel, here's the crazy part. We've known about this since the 1990s. We've had products since the 1970s." [2] Why don't women know? "No one ever taught your doctors this. No one ever talked about it publicly because the two dirtiest words in the English language are vagina and estrogen. And so because we can't say those words, no one is prescribing this." [2] She cites a JAMA paper from a Stanford colleague finding that among more than a million Medicare patients with a symptom of genitourinary syndrome of menopause, only 9 percent received a prescription [2].

A warning label and a study. Rubin traces the fear of hormone therapy to the 2002 Women's Health Initiative, when, she says, the NIH held a press conference before the paper was published declaring that hormones cause breast cancer and cardiovascular disease [2]. Prescriptions collapsed overnight [2]. The lasting damage, she argues, is generations of clinicians never taught to prescribe [2]. Until recently, all estrogen products, vaginal ones included, carried a boxed warning about stroke, blood clots, heart attack and probable dementia, which she calls false for vaginal hormones; she describes a long campaign that led the FDA to announce its removal [2]. Her conclusion: "there are no grownups coming to save the day" [2].

Testosterone and the FDA. Rubin says "for women we have no FDA approved testosterone product for women none zero," though one is approved in Australia, New Zealand, South Africa and England [2]. She says a large trial showed benefit for libido, but the FDA asked for five more years of data around the time of the Women's Health Initiative and the effort died [2].

Specialists are few. "The most important message I can tell your amazing listeners is sex should not be painful and you deserve a diagnosis," Rubin says [2]. There are far fewer specialists for this part of the body "because we haven't valued or cared about this part of the body for women. So it is likely that your general doctor, who you've been seeing for a long time, isn't necessarily, they might be, but isn't necessarily trained in the specific diagnosis." [2] She blames ten-minute visits on the system and insurers more than on doctors, and recommends asking a clinician directly whether they are the right person to help [2].

Mary Claire Haver: a blind spot for a third of women's lives

Mary Claire Haver is a board-certified OB-GYN, a certified menopause practitioner through the Menopause Society, and author of The New Menopause [3][4]. She spoke about the gap with both Mel Robbins and Andrew Huberman.

Her own training. Haver says she's passionate about this "Because in my own journey of going through menopause and realizing what a gap there was in my own training and how I really wasn't the best menopause provider for a long time" [3]. Medical students, residents and nurse practitioners, she says, aren't taught "much about menopause care outside of the most cliche of symptoms and how to manage them" [3]. "Menopause and estrogen decline is inevitable the way that we're created as humans. But suffering through it and having to just put up with it or dismissing it as a sign of aging is not." [3] And "We're going to live a third of our lives like this." [3]

The patients she sent away. Haver shares an uncomfortable story from her residency in Texas: upper-level residents would grab the surgical cases and leave interns with a patient labeled with an acronym meaning whining woman, a desperate patient who couldn't sleep, was gaining weight, felt unhappy, had headaches, and still had periods [3]. "I would start sending her to other specialists. Like let's go see a cardiologist for the palpitations and the, you know, a neurologist for your headaches," she says, "and she'd walk out of my office with six referrals. And I didn't know enough to say, let's try some hormone therapy and see if these things get better." [3] Her conclusion: "We got to do a better job training every single healthcare professional in all specialties about how special menopause is and what the lack of estrogen is doing to each and every organ system." [3] Part of the difficulty is variety: "Each female has a unique expression of our menopause," and "doctors like a checklist of symptoms." [3]

The research gap in numbers. Haver illustrates the gap with PubMed. On Mel Robbins's show, she says searching pregnancy returns about 1.1 million articles, while "When you put in the word menopause, we get 94,000 articles. We only get 10% of the funding." [3] With Huberman, she gives about 97,000 articles on menopause and roughly 6,400 on perimenopause, and says menopause receives about 0.03% of NIH funding: "When you look at all NIH funding and what goes to menopause, it's .03% less than half a percent. This is one third of a woman's life." [4] She also cites a McKinsey analysis finding that only about half of studies on chronic diseases reported results by sex [4]. Women live a little longer than men, "but we're going to spend 20% of that in poor health, in decline, in disability, and this is avoidable." [3]

Her own specialty. Haver is critical of OB-GYN itself. She tells Huberman, "as a women's health specialist, we did this to ourselves. You know, we have not properly educated ourselves." [4] The American Board of Obstetrics and Gynecology's annual reading lists contain no menopause category, and fewer than 1% of articles in her journals over ten years dealt with menopause [4]. Her nutrition training amounted to one lecture and a faded photocopy of a gestational diabetes diet [4]. "We are females and we're not little men with breast and uterus. We react differently to medications, disease, disease burden, you know, and that's not been studied adequately," she says, arguing menopause education belongs in every medical school curriculum [4]. "I hate saying women's health because everyone thinks breast and uterus, right, and reproduction. It's the health of women." [4]

The symptoms that get missed. Haver describes perimenopause as starting typically 7 to 10 years before periods stop, often between 35 and 45, and showing up as irregular or heavy periods, brain fog, joint pain, frozen shoulder, gut problems, new asthma or autoimmune disease, and dryness [3]. With Huberman she adds palpitations that can be mistaken for panic attacks, vertigo, tinnitus and itchy skin, and cites at least a 40% increase in mental health disorders and a doubling of SSRI use across the transition [4]. She notes UK data showing "one in five women will quit their jobs because of menopause symptoms." [4] Her youngest patient with premature ovarian insufficiency was 27, and spent 18 months getting a diagnosis [4]. Because hormone levels change so unpredictably, there is no good blood test for perimenopause; clinicians diagnose it by symptoms while ruling out thyroid disease, autoimmune conditions, nutritional deficiencies and anemia [4].

Practical barriers. Medicare does not pay for a menopause visit, Haver says, so she suggests booking a separate appointment to discuss symptoms rather than trying to cover everything in a short well-woman exam [3]. Only about 10% of women who report menopausal symptoms are offered any therapy [4]. She calls the fallout from the Women's Health Initiative "the worst misinformation campaign in the history of medicine" [4]. "Not every woman will choose HRT, but every woman deserves an informed conversation about it." [4]

A generation away. Haver thinks it may take a generation for primary care doctors and OB-GYNs to routinely handle menopause well: "We're probably a generation away from this becoming normal." [3] For now she points to her website's list of doctors recommended by followers, the Menopause Society's directory at menopause.org, and telemedicine companies built for menopausal women, where clinicians "sit there listen to your symptoms believe you order a test if you need them" [3]. Her final line on it: "we need to normalize this before we can optimize it." [3] Huberman, for his part, encourages listeners to call their elected representatives to push for more research funding [4].

Sharon Malone: one continuous story nobody tells

Sharon Malone is a board-certified OB-GYN with nearly 40 years in practice and the author of Grown Woman [5]. Her central message is that the stages of a woman's hormonal life connect.

One story. "I think the most important thing that women should understand is that we are hormonal beings," Malone says. She adds that "these hormonal changes and undulations that happen affect every part of our body. And they're not disconnected." [5] Puberty, the reproductive years, perimenopause and menopause are linked: "It is one continuous story. And that the sooner you know the story, the better you're able to craft a better ending for you." [5] Mel Robbins describes the opposite experience: health handled "almost like episode by episode," a period problem, then weight or sleep or brain fog, each treated on its own [5].

The silence starts early. Malone says the problem starts with the conversations we don't have between generations [5]. Most girls barely get a period talk, and when they do, it covers pads and tampons rather than the fact that the body is undergoing a total transformation [5]. The same silence repeats decades later in perimenopause, when, as she puts it, "No one warns you." [5] She traces this to a long history of women being taught that what their bodies do is shameful [5].

The great masquerader. Endometriosis shows the pattern clearly. It affects about one in ten women and is a leading cause of painful periods and infertility [5]. Malone calls it "the great masquerader" because symptoms show up wherever it lands, such as bowel or bladder problems, so women get sent to a GI doctor or a urologist for each symptom without anyone seeing the pattern [5]. Many women also assume painful periods are normal [5]. The result is a diagnostic delay of seven to nine years, despite repeated doctor visits [5]. On PCOS, her frustration is that the field has changed the name while making little progress on why it happens or how to treat it [5].

Menopause as a life stage. Malone says "menopause is not an event. It is a life stage." "You will spend 30 to 40% of your life after you have completed menopause." [5] She warns that "hot flashes are not benign": more severe and frequent hot flashes can be a marker for later cardiac issues, and they set off a chain of night sweats, disrupted sleep, and higher risks of cardiovascular disease, high blood pressure and type 2 diabetes [5]. Black women have hot flashes that start earlier, are more severe and last longer [5]. Her line on enduring symptoms: "misery should not be your resting place." [5]

Late diagnosis by design. Malone questions the standard advice to get a first bone density scan at 65, since the fastest bone loss comes in the first five years after menopause; she advises a baseline scan at menopause and a repeat 18 months to two years later [5]. She says women often wait for hormone therapy because they don't recognize their symptoms as perimenopause, and because of the old advice to take the smallest dose for the shortest time [5].

Attention to women's health. Asked about the estrogen patch shortage, Malone says she is glad demand has grown but frustrated no one saw it coming [5]. "I have personally been out here in this space talking about menopause publicly for over five years. I've been talking about it privately for 35 years," she says, and adds, "I think that there's not a lot of attention being paid to women's health" [5].

Use your family as data. Malone urges women to ask their mothers about their reproductive history: whether they had trouble conceiving, how old they were at their last baby, when they stopped birth control, whether they had painful cramps or fibroids [5]. She calls it data, and it can speed up a diagnosis [5].

Where They Agree, and Where They Don't

Where they agree

Training left doctors unprepared. Shah's OB-GYN colleagues told her they didn't learn about it [1]. Rubin says gynecology training doesn't cover sexual medicine and other doctors defer to gynecology [2]. Haver says she wasn't a good menopause provider for a long time and that her specialty "did this to ourselves" [3][4]. Malone says not much attention is paid to women's health [5].

Research has lagged. Shah describes women's exclusion from studies and the lack of hormonal data even now [1]. Haver gives PubMed and funding figures and the McKinsey finding on sex-specific results [3][4]. Rubin describes the FDA asking for five more years of testosterone data until the effort died [2]. Malone wants research on PCOS focused on causes and treatment rather than names [5].

Symptoms get split up. Shah asks doctors not to "write it off as separate things" [1]. Haver sent patients away with six referrals [3]. Malone describes endometriosis patients sent to a GI doctor or urologist for each symptom [5]. Robbins describes her own care as episode by episode [5].

Women get dismissed. Shah calls it medical gaslighting [1]. Rubin lists the wine-and-novel advice women receive [2]. Haver's residency story centers on an acronym meaning whining woman [3]. Malone says women's symptoms are often dismissed [5].

One study cast a long shadow. Rubin and Haver both trace the fear of hormone therapy to the 2002 Women's Health Initiative and how its results were announced [2][4]. Shah notes the old fear that hormone therapy causes cancer has shifted [1], and Malone says misconceptions about breast cancer and negative press about hormone therapy have been knocked down [5].

Diagnosis by symptoms. Shah says menopause is diagnosed by symptoms, not hormone levels [1]. Haver says there is no good blood test for perimenopause [4]. Malone advises treatment when symptoms bother you [5].

Vaginal estrogen is underused. Rubin says only 9 percent of Medicare patients with a symptom got a prescription [2]. Haver says local vaginal estrogen should be used by essentially every woman and is the best treatment for recurrent urinary tract infections in menopause [3][4]. Malone explains that vaginal estrogen treats what systemic therapy may not [5].

Where they don't

Whose fault the gap is. Shah emphasizes research design: women excluded, then included without measuring hormones [1]. Rubin emphasizes training and taboo, and says the problem is untaught doctors, not bad ones, with ten-minute visits a failure of the system and insurers [2]. Haver puts blame on her own specialty [4]. Malone starts earlier, with silence between generations and shame about women's bodies [5].

The numbers differ, even from one doctor. Haver cites about 94,000 menopause articles and 10% of funding on one show [3], and about 97,000 articles and 0.03% of NIH funding on another [4]. The sources don't explain the difference, so the exact numbers are best held loosely; both versions show a large gap.

Whether hormones help with weight. Shah is direct: "hormone replacement therapy does not help with the weight gain part," which she says involves reduced activity, muscle loss and disrupted sleep [1]. Malone says there is real medical benefit to starting sooner for heart risk, weight and sleep [5]. Haver says women on hormone therapy alongside a GLP-1 drug have 30% more weight loss [4].

Oral or not. Haver generally prefers non-oral estrogen because oral estrogen passes through the liver and can slightly raise clotting factors, and avoids it entirely for women with a clotting history [4]. Malone calls oral estrogen a sound option and notes that most of the data on hormone therapy's benefits come from oral use [5].

Testosterone. Shah warns that testosterone pellets often produce levels far above the therapeutic range and are popular partly because practitioners can charge for them [1]. Rubin prescribes generic male gel at about one tenth of a man's dose and is cautious about pellets because the dose cannot be removed once implanted [2]. Haver prescribes a compounded transdermal cream [4].

How long and when. Haver argues estrogen is protective for women who start within roughly the first 10 years of menopause, though older women can still consider it after screening [3][4]. Malone says there is no time limit on how long you can take hormone therapy and advises starting when symptoms bother you [5]. Shah says evidence suggests hormones can be protective when started close to the onset of perimenopause or menopause [1].

Why It Works

The sources explain the blind spot through several mechanisms.

Studies built around men. Shah says women were excluded because of fluctuating hormones and possible pregnancy, given smaller doses of drugs tested on men, and are still rarely studied for hormonal effects [1]. Haver adds that only about half of chronic disease studies reported results by sex [4]. Without the data, doctors have little to go on.

Specialties that don't connect. Rubin describes a division in which gynecology covers reproduction, not sexual medicine, while other specialists assume women's issues belong to gynecology [2]. Haver's six referrals and Malone's account of endometriosis show symptoms routed to cardiology, neurology, gastroenterology and urology, each seeing one piece [3][5].

Hormones touch every organ. Haver says every organ system has estrogen receptors, from joints and heart to gut, bones and the genitourinary system [3]. That is why the symptoms look unrelated: frozen shoulder, palpitations, asthma, brain fog and urinary infections can all trace back to the same change [3][4]. Malone's "they're not disconnected" makes the same point across a lifetime [5].

Symptoms vary, and doctors want checklists. Haver says each woman has a unique expression of menopause while doctors like a checklist [3]. Perimenopause has no good blood test because hormone levels swing unpredictably [4]. Shah says menopause is defined by symptoms, not levels [1].

Fear left over from 2002. Rubin and Haver describe a press conference before publication, a single pill and dose unlike today's options, and participants averaging past the usual age of menopause [2][3][4]. The fallout, they say, was a generation of clinicians never taught to prescribe and a boxed warning on vaginal products that Rubin calls false [2].

Taboo. Rubin's "two dirtiest words" and Malone's account of shame and silence explain why women don't ask and doctors don't raise it [2][5].

Systems that don't pay for the conversation. Haver says Medicare does not pay for a menopause visit [3], and Rubin blames ten-minute visits on the system and insurers [2].

Where It Applies, and Where It Doesn't

Not every symptom is hormonal. Rubin is careful to add that not every medical problem is hormonal [2]. Haver rules out thyroid disease, autoimmune conditions, deficiencies and anemia before attributing symptoms to perimenopause [4]. Shah notes that anxiety medications have their place: "There's a great need for medications, but there's also a big need for education" [1].

Not every woman is a candidate for every treatment. Haver lists absolute contraindications for hormone therapy, including undiagnosed vaginal bleeding, active breast cancer, an active blood clot or an active stroke, while noting a family history of breast cancer is not one [3]. A history of breast cancer is a nuanced conversation, not an automatic disqualification [4].

It isn't only menopause. Rubin says genitourinary symptoms can occur on birth control pills, during breastfeeding and on endocrine therapy for breast cancer [2]. Malone's continuous story covers periods, endometriosis, PCOS and fertility in women's 20s and 30s [5]. Perimenopause can begin in the mid-30s [1][3][5].

Evidence is uneven. Rubin acknowledges the strongest testosterone data concern libido and that more data are needed on younger women [2]. Haver says there aren't great studies on how best to support women in perimenopause [3], and calls collagen's mechanism an area for more research [4]. Rubin's episode, the summary notes, is a single-expert advocacy conversation in which claims are not challenged on air [2].

Who is missing from the data. Shah says differences by race and ethnicity haven't been studied [1]. Malone notes that Black women have hot flashes that start earlier, are more severe and last longer [5], and Haver says African American women go through menopause about a year and a half earlier [4].

Change is underway, but slowly. Rubin describes the boxed warning's removal and new urology guidelines [2]; Malone sees rising demand for estrogen patches as women wake up to the facts [5]; Haver credits social media with letting women find each other, while expecting a generation before routine care catches up [3].

What To Do With It

These steps come from the sources; they are a starting point for a conversation with a qualified clinician, not a substitute for one.

1. Track your symptoms as one picture. Shah asks doctors to think about where a woman is in her cycles and hormones rather than treating complaints separately; bring that view to your own appointments, and track your cycle as Robbins suggests [1][3].
2. Book a visit just for this. Haver suggests a separate appointment to discuss symptoms rather than squeezing them into a short well-woman exam [3].
3. Ask whether this doctor is the right person. Rubin recommends arriving educated and asking directly whether the clinician is the right person to help [2].
4. Find a trained clinician if needed. Haver points to the Menopause Society's directory of certified practitioners at menopause.org; Rubin points to the International Society for the Study of Women's Sexual Health and the Menopause Society [2][3].
5. Don't rely on hormone tests to diagnose menopause. Shah says it is a diagnosis of symptoms, and Haver says perimenopause has no good blood test [1][4].
6. Ask about the root cause of recurring infections. Rubin says a UTI needs its underlying hormonal cause treated, not antibiotics alone, and that vaginal estrogen or vaginal DHEA prevents urinary tract infections by more than half [2]. Haver says vaginal estrogen is the best treatment for recurrent urinary tract infections in menopause, rather than chronic antibiotics [3][4].
7. Ask both questions about hormone therapy. Malone advises asking what the benefits of taking it are and what will happen if you don't [5].
8. Talk to your mother. Malone's questions about conception, cramps, fibroids and the age of menopause give you data, and Haver asks patients when their mothers and aunts went through menopause [4][5].
9. Get a bone scan earlier. Malone advises a baseline bone density scan at menopause rather than waiting until 65 [5].
10. Push for research. Huberman encourages listeners to call their elected representatives for more menopause research funding, and Haver argues menopause education belongs in every medical school curriculum [4].

Sources

1. Dr. Amy Shah on Women's Hormones from PMS to Menopause: Weight, Sleep, Anxiety and What Helps · The Mel Robbins Podcast
2. Dr. Rachel Rubin on Vaginal Hormones, UTIs, Testosterone and Women's Sexual Health · The Mel Robbins Podcast
3. Dr. Mary Claire Haver on Menopause: Estrogen, Belly Fat, Sleep, and a Toolkit to Stop Suffering · The Mel Robbins Podcast
4. Dr Mary Claire Haver How To Navigate Menopause Perimenopause For Maximum Health Vitality · Huberman Lab
5. Dr. Sharon Malone on Women's Hormones from Your 20s to Menopause: Birth Control, Fertility, PCOS, Endometriosis, HRT and Bones · The Mel Robbins Podcast